Research presented at Digestive Disease WeekÂ® 2007 (DDWÂ®) examines a new endoscopic suturing method for the treatment of gastrointestinal perforations and other types of transgastric surgery, as well as the use of wireless capsule endoscopy in young children, to better understand the pathology of the small intestine. Endoscopic procedures are continually enhancing and improving a physician’s ability to evaluate, diagnose and treat gastrointestinal (GI) disorders. The development and evaluation of innovative techniques and the use of proven techniques in new settings is expanding the set of tools physicians have to work with to provide the best care for patients. DDW is the largest international gathering of physicians and researchers in the fields of gastroenterology, hepatology, endoscopy and gastrointestinal surgery.

“The quality and delivery of evaluation, diagnosis and treatment of the GI tract and surrounding areas is constantly improving due to newer and better endoscopic procedures,” said Gregory Ginsberg, M.D., AGAF, University of Pennsylvania Health System. “This translates into both increased knowledge about the GI tract and related diseases and safer and more effective care for patients.”

Early Clinical Experience with a New Simple Flexible Endoscopic Suturing Method for Intra-Luminal and Transgastric Surgery (NOTESâ„¢) (Abstract #344)

With the emergence of the novel surgical technique known as Natural Orifice Transluminal Endoscopic Surgery (NOTESTM), physicians and researchers are discovering new and minimally-invasive ways to conduct abdominal operations. NOTES is performed by passing an endoscope through a natural orifice, such as the mouth or anus, then making an internal incision in the stomach, colon, bladder or vagina, thus avoiding external incisions or scarring. Since its introduction in 2004, many physicians have tested this concept to determine its strengths, weaknesses and potential solutions.

In this study, researchers from Gothenberg and London tested new technology applicable to NOTES as well as intraluminal endosurgery – specifically, a new flexible endoscopic suturing method for intraluminal and transgastric surgery. Researchers evaluated the technique in porcine models and then reported the first clinical results in three patients. While many devices have been constructed to perform endoscopic suturing, most are complicated, expensive and difficult to use. Researchers evaluated the new method and found that it was not only easy to employ, but allowed for successful closure of perforations and approximate tissue without laparoscopic or open surgery.

The method involves passing flexible needles constrained within a plastic catheter loaded with metal tags down the working channel of a conventional endoscope. Two tags are placed into the wall of the stomach, one on each side of the defect. The threads are then locked together and cut. Precise stitch positioning is performed in the middle of the visual field and multiple stitches can be placed quickly without the need to remove the endoscope during the procedure.

Using this technique, researchers were able to close a perforated duodenal ulcer (ulcer in the small intestine) and leaking anastomosis (surgical connection of separate or severed parts of a tubular organ, such as the intestine) and stop upper gastrointestinal bleeding in patients when other methods had failed. They were also able to close perforations and perform gastro-jejunostomies (surgical formation of a passage between the stomach and small intestine) and pyloroplasty (surgery to open up narrowing of the junction between the stomach and duodenum) in porcine models.

“This method makes endoscopic suturing possible almost anywhere in the GI tract that can be reached by a flexible endoscope,” said C. Paul Swain, M.D., of Royal London Hospital in London, UK and lead author of the study. “More studies are needed to provide further evidence that this and other types of natural orifice transluminal endoscopic surgery techniques are safe and effective. Randomized studies comparing this flexible suturing method with conventional surgery have been undertaken by our group in combination with others to examine the effect on closure of four centimeter incisions in the pig colon. Another randomized study has been undertaken to test the efficacy of this system in closing gastrotomy incisions for NOTES procedures. More human studies are planned.”

The Feasibility of Wireless Capsule Endoscopy in Detecting Small Intestinal Pathology in Young Children Less Than Age 8 Years (Abstract #M1402)

Many medical procedures and devices used to detect problems or disease in adults have not been tested, and therefore are not used, in children. While all procedures and devices used in adults may not be appropriate for use in children, some may lead to increased understanding of disease pathology and better diagnosis of certain disorders in the pediatric population. Wireless Capsule Endoscopy (WCE) is not widely used in small children (no FDA approval for children <10) due to inherent problems in swallowing the capsule. To overcome this difficulty, some investigators have used adult introducer devices to endoscopically place the capsule into the gut. These methods are cumbersome and potentially traumatizing.
Researchers from children's hospitals throughout Europe tested the use of WCE in small children as a means of investigating the small intestine (SI), which is difficult to examine thoroughly with other endoscopic procedures. WCE utilizes a video capsule that, once swallowed, travels through the SI to acquire and transmit digital images. The study aimed to determine the ability of WCE in children <8 years of age, to compare endoscopic means of introduction, and to define the pathologies encountered to evaluate the need for capsule endoscopy in this age group.
The multi-center trial enrolled 56 patients ranging from age one and a half to eight. All patients underwent barium meal and follow through, and upper and lower gastrointestinal (GI) tract endoscopy prior to enrollment. After 12 hours of fasting, patients were given the capsules. Twenty-three were able to swallow the capsule easily, and 33 required endoscopic introduction.
The capsule procedure was successful in all patients down to the age of one and a half. The images revealed important age-specific disorders, including suspected GI bleeding (n=23), Crohn's disease (n=15), abdominal pain (n=10) and protein loss (n=8). One adult endoscopic introducer proved to be quite traumatizing, yet important information in developing pediatric use was determined. The size of the capsule was too large and the weight of the batteries too excessive for the youngest children involved in the trial.
"This preliminary data shows that wireless capsule endoscopy is a viable and safe means of examining the small intestine in very young children and confirms the utility of this practice in detecting occult gastrointestinal bleeding in children, which has been a challenge in the past," said Annette Fritscher-Ravens, M.D., of Homerton University Hospital in London, UK, and lead author of the study. "Additional studies are needed to further validate the safety and efficacy of this practice, as it will lead to increased knowledge and earlier diagnosis of gastrointestinal problems in this age group."
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Digestive Disease WeekÂ® (DDWÂ®) is the largest international gathering of physicians, researchers and academics in the fields of gastroenterology, hepatology, endoscopy and gastrointestinal surgery. Jointly sponsored by the American Association for the Study of Liver Diseases (AASLD), the American Gastroenterological Association (AGA) Institute, the American Society for Gastrointestinal Endoscopy (ASGE) and the Society for Surgery of the Alimentary Tract (SSAT), DDW took place May 19-24, 2007 in Washington, D.C. The meeting showcases more than 5,000 abstracts and hundreds of lectures on the latest advances in GI research, medicine and technology.
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